ABSTRACT
In health care as in aviation, accidents typically are attributed to human error. Not only does this occur in the media, but also people tend to blame themselves when involved in an error while working in a professional capacity. This is particularly true for health care providers who are taught they are responsible for whatever happens to the patient. The literature in a number of domains including aviation indicates that error is the result of an alignment of conditions and occurrences each of which is necessary, but none alone sufficient to cause the error. That alignment of factors creates error-provoking conditions affecting the context in which an incident occurs. The prevailing presumption in health care and its literature. however, is that the source of medical error is the care provider. This presumption is self-validating; once the source of error has been identified, there is no further search for the cause to disconfirm that finding, hence the presumption is validated. The ensuing discussion (a) illustrates how the presumption that the person is the source of error influences not only the development of research methodology, but also the interpretation of research findings, and (b) presents the systems approach to medical error (SAME) as a technique for stretching the search for the why of error beyond the care provider to factors affecting the context of care.
